Significance of Keratinized Mucosa/Gingiva on Peri-Implant and Adjacent Periodontal

Conditions in Erratic Maintenance Compliers

Alberto Monje, DDS, MS*†, Gonzalo Blasi, DDS, MS†‡

* Department of Oral Surgery and Stomatology, ZMK School of Dental Medicine, University of
Bern, Switzerland

† Department of Periodontology, International University of Catalonia, Barcelona, Spain

‡ Division of Periodontology, University of Maryland School of Dentistry, Baltimore, Maryland,

USA

Corresponding Author:

Alberto Monje DDS, MS

Department of Oral Surgery and Stomatology

School of Dental Medicine, University of Bern

Freiburgstrasse 7, 3010 – Bern (Switzerland)

E-mail address: [email protected]

Word account: 3549; Figures: 4; Tables: 2; References: 49

Running title: Keratinized mucosa/gingiva around implants and teeth

One sentence summary: The presence of keratinized mucosa in erratic compliers is associated with

healthy peri-implant conditions.

This is the author manuscript accepted for publication and has undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1002/JPER.18-0471.

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Mesh Keywords: Peri-implantitis, Peri-implant mucositis, Dental implants, Implant stability,

Diagnostic, Alveolar bone

Disclaimer: The authors have no direct financial interests with the products and instruments listed in

the paper.

Abstract

Background: Given the fact that most patients are not regular compliers in supportive peri-implant

maintenance programs, it is of interest to examine the significance of the peri-implant soft tissue

characteristics in relation to the onset of peri-implant diseases.

Material and Methods: Based on an a priori statistical power calculation, a cross-sectional study was

conducted on erratic peri-implant maintenance compliers (< 2x/year) in order to examine the

significance of keratinized mucosa (KM) and gingival tissue (KT) on peri-implant and adjacent

periodontal conditions in implants restored ≥ 3 years. Seven clinical parameters were recorded around

implants and the adjacent buccal sites. Radiographic assessment was carried out using periapical X-

rays. In addition, a visual analog scale (VAS) was used to evaluate the impact of KM upon brushing

comfort. The case definition used for peri-implant diseases was in accordance with the 2017 world

workshop on the classification of periodontal and peri‐ implant diseases and conditions.

Results: Overall, 37 patients with 45 edentulous gaps restored with 66 implants and 90 adjacent teeth

were analyzed. On comparing a KM band of < 2 mm versus ≥ 2 mm, with the exception of

suppuration (p=0.6), all the clinical and radiographic parameters were significantly increased when

the KM band was < 2 mm (p ≤ 0.001). A significant correlation was observed between KM and KT

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(r=0.55), though a lack of KM did not condition a lack of KT. In the presence of peri-implantitis, only

bleeding on probing at the adjacent dentate sites was identified to be increased.

Conclusion: The presence of < 2 mm of KM around dental implants in erratic maintenance compliers

seems to be associated with peri-implant diseases. The lack of KM constitutes a site-specific

phenomenon independent of the keratinized tissue present in the adjacent dentition (NCT03501537).

Introduction

The morphological characteristics of the gingiva have been regarded as crucial for the integrity of the

periodontium.1 This claim is based on the fact that movable mucosa facilitates the penetration of

biofilm into the crevice, which in turn would trigger the activation of neutrophils and lymphocytes. 2

These would cause chronification of the inflammatory response, resulting in attachment loss. 3 Hence,

it has been advocated that an adequate zone of keratinized tissue (KT) with an attached area are

decisive in order to maintain the stability of the periodontal tissues. 4 This requirement is of lesser

relevance in patients with adequate plaque control, however.5-7

The significance of keratinized mucosa (KM) bordering dental implants has not been without

controversy, and focused much debate especially during the 1990s.8-12 The reason for this academic

disagreement was mainly the fact that the vast majority of commercial dental implants at the time

were machined/turned designs which in turn may minimize biofilm accumulation when compared to

modified surfaces. This issue is of considerable significance, since plaque accumulation may lead to a

greater inflammatory infiltrate dominated by lymphocytes and plasmatic cells when compared to

natural teeth.13 In this regard, a meta-analysis of recent trials revealed statistically significant

differences in plaque index, modified gingival index, mucosal recession and attachment loss, with

results all favoring implants with a wide band of KM.14 In this sense, the lack of KM is positively

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associated to vestibular depth15 and brushing discomfort,16, 17 which can condition patient willingness

and ability to acquire adequate personal oral hygiene habits. In addition, the presence of KM around

dental implants has been shown to have an impact upon immunological parameters, with a negative

correlation to prostaglandin E2 levels.18

Supportive periodontal therapy (SPT) and peri-implant maintenance therapy (PIMT) have been shown

to be crucial to the longevity of both natural teeth19-23 and dental implants.24-29 In this regard, the

compliance rate has also been shown to potentially condition the development of biological

complications. Findings from a recent systematic review suggest that compliance with a biannual

PIMT program results in an approximately three-fold increased efficacy in the prevention of peri-

implant diseases. In agreement with this, clinical trials have underscored the importance of

professionally providing PIMT ≥ 2 times/year compared with less frequent recalls.24, 29 Nonetheless,

approximately 60% of all patients are either erratic compliers (< 2x/year) or non-compliers (0x/year),

and of these, roughly one out of five develop peri-implantitis.24 Given the fact that even in the absence

of adequate PIMT enrollment the majority of erratic compliers or non-compliers do not develop

pathological conditions characterized by progressive bone loss, it seems of interest to examine the

influence of KM in these patients.

The present study thus assesses the significance of KM in erratic (< 2x/year) compliers. In addition,

an evaluation is made of the influence of the band of KM upon the peri-implant conditions in

comparison to the periodontal conditions of the adjacent teeth.

Material and Methods

A cross-sectional study was conducted in accordance with the Declaration of Helsinki on human

studies, following approval from the Ethics Committee of the University of Extremadura (Badajoz,

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Spain, Ref. no. #18002909). The subjects were recruited for the study from February 1st until June 15th

of 2018. The study was also registered and approved by www.clinicaltrials.gov (NCT03501537), and

is reported according to the STROBE statement (www.strobe-statement.org). Written informed

consent was obtained from all patients for this study.

Study population

All enrolled subjects had been consecutively evaluated with dental implants in function and a screw-

retained fixed prosthesis for a minimum of 36 months after final prosthesis delivery. All eligible

patients had to fall within the following definition of erratic compliance: not attending to a minimum

of 2 times (i.e., every 6 months) for supportive periodontal/peri-implant maintenance therapy.24

Patients were either contacted and invited to participate in a study to identify the peri-

implant/periodontal conditions or the evaluation was carried out during supportive periodontal/peri-

implant treatment performed in a Private Practice exclusive in Periodontics and Implant Dentistry

(CICOM | Periodoncia, Badajoz, Spain). The clinical, radiographic analyses were carried out by one

periodontist (AM) with more than 5 years involved in clinical research accredited by the American

Academy of Periodontology (ABP). The baseline x-rays at the time of prosthesis delivery were

retrospectively examined to exclude implants with excessive early peri-implant bone loss before

function that could lead to misdiagnosis.

All included patients were informed – as part of the initial phase - to adhere to a supportive peri-

implant maintenance therapy program tailored to the risk profile. As such, patients with history of

periodontal disease were recommended to attend every 3-4 months and patients without history of

periodontal disease were suggested to comply every 5-6 months. Supportive periodontal/peri-implant

maintenance therapy was carried out by an experienced hygienist (>5 years of expertise) with plastic

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curettes and fine polishing pastes. Moreover, recommendations on home care were delivered stressing

on the use of inter-proximal brush and floss with stiffened end to cleanse the inter-proximal areas.

The prescreening was performed by reviewing the internal records. An a priori statistical power

analysis was carried out to calculate the sample size. Overall, 37 patients were determined to be

recruited assuming an intra-class correlation coefficient of 0.25. All the eligible patients were

consecutively invited when attending to other departments at the same practice for other

reasons/concerns (i.e., prosthodontics, oral & maxillofacial surgery and orthodontist) or when

irregularly attended to the supportive periodontal/peri-implant treatment. Along the recruitment

period, 3 patients resulted to be current smokers and hence were invited to adhere to a regular

supportive peri-implant maintenance therapy but excluded from the study.

Eligibility criteria

The following inclusion criteria were applied: implant-supported single-crown and fixed prostheses,

patients aged 18-80 years; non-smokers; absence of infectious disease at the time of implant

placement or during the maintenance program; absence of systemic disorders or medication known to

alter bone metabolism; partially edentulous patients with gaps associated to at least one mesial and

one distal adjacent tooth, without sign of active periodontal disease and with or without a history of

chronic periodontitis. Subjects in turn were excluded for the following reasons: pregnancy; lactation;

past or present heavy smoking; uncontrolled medical conditions such as diabetes mellitus; inadequate

three-dimensional implant positioning impeding accurate recording of probing depth; cement-retained

restorations or restorations lacking KM on the lingual implant sites.

Case definition of peri-implant health, mucositis and peri-implantitis

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Based on the consensus report of Workgroup 4 of the 2017 World Workshop on the Classification of

Periodontal and Peri‐Implant Diseases and Conditions 30, the diagnosis of health required:

 No clinical signs of inflammation.

 No bleeding and/or suppuration on gentle probing (0.15 Ncm).

 No increase in probing depth compared to previous examinations.

 No bone loss beyond crestal bone level changes resulting from initial bone remodeling.

The diagnosis of peri-implant mucositis in turn was established from the following:

 Presence of bleeding and/or suppuration on gentle probing (0.15 Ncm).

 No bone loss beyond crestal bone level changes resulting from initial bone remodeling.

Lastly, the diagnosis of peri-implantitis in turn was established from the following:

 Presence of bleeding and/or suppuration on gentle probing (0.15 Ncm).

 Probing depth ≥ 6 mm.

 Bone level ≥ 3 mm apical to the most coronal portion of the intraosseous part of the implant.

Clinical assessment

The following clinical parameters and indexes were recorded at the buccal sites of the studied

implants and teeth:

 Probing pocket depth (PPD) recorded in mm using a North Carolina Probe.

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  Modified sulcular bleeding index (mBI) scored from 0-3 according to the extent and severity

of bleeding on probing (BOP).31

 Plaque index (PI) scored from 0-3 according to the visibility and severity of plaque

accumulation.32

 Keratinized mucosa (KM) around dental implants, measured from the free mucosal margin to

the mucogingival junction at the mid-buccal, mesial and distal line-angles, and recorded to the

nearest mm using a North Carolina Probe. If unclear, Lugol’s iodine was used to stain the

mucosa to better discern the mucogingival margin. The firm and resilient KM was identified

as attached mucosa (AM).

 Keratinized gingival tissue (KT) around natural dentition, measured from the free mucosal

margin to the mucogingival junction at the mid-buccal, mesial and distal line-angles, and

recorded to the nearest mm using a North Carolina Probe. If unclear, Lugol’s iodine was used

to stain the mucosa to better discern the mucogingival margin.

 Vestibular depth (VD) measured using a North Caroline Probe from the mucosal margin to

the point of greatest concavity of the mucobuccal fold while a retracting with a bilateral

retractor. Vestibular depth was rated as shallow (< 4 mm) or deep (≤ 4 mm).

 Suppuration (SUP) around implants and teeth, recorded by a dichotomous (1/0) scale using a

North Carolina Probe.

Moreover, the patients were interviewed by one examiner (AM) using a visual analog scale (VAS) to

assess brushing comfort prior to assess the clinical condition to minimize bias. The VAS recorded a

characteristic (comfort) ranging across a continuum of values, and which is not easy to measure

directly. The score ranged from 0 (maximum discomfort) to 100 (maximum comfort) and was

recorded around teeth and implants.

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Radiographic assessment

One examiner (AM) assessed the radiographic bone level (intra-rater Cohen kappa value >90% -

almost perfect). Peri-implant radiographic bone loss (MBL) was determined by taking linear

measurements from the most mesial and distal point of the implant platform to the crestal bone on

each peri-apical radiograph, corrected according to the known height and width of each implant using

ImageJ (National Institutes of Health).

Statistical analysis

A priori statistical power analysis was performed assuming an intra-class correlation coefficient (ICC)

of 0.25, based on a previous study.33 The Kolmogorov-Smirnov test was applied to assess normality

between the parameters KM and KT. Pearson’s correlation coefficient was used to assess the

correlations between the presence/lack of KM in the edentulous gap and the other clinical and

radiographic parameters or KT of the adjacent teeth. The Mann-Whitney U-test was applied to

validate the homogeneity of the clinical parameters for teeth and implants. In the event of a non-

homogeneous distribution, we used the Spearman correlation test. The Kruskal-Wallis test was

applied to assess homogeneity of one of the variables in ≥ 3 independent samples.

The inferential analysis involved estimation by generalized estimating equations (GEEs) of multilevel

logistic regression models. Calculations were made to assess any parameter recorded at implant-level

in relation to KM. The level of significance was defined as 5% (α=0.05).

Results

Study population

Based on the a priori sample size calculation, 37 Caucasian patients (37.6% females, 32.4% males;

mean age: 49.9±12.9 years) with 45 edentulous gaps restored with 66 implants (mean follow-up:

5.73±2.89 years) and 90 adjacent teeth were analyzed. Of these, 30 (81.1%), 6 (16.2%) and 1 (16.2%)

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patients respectively had 1, 2 and 3 implant-supported edentulous gaps. Overall, 18 (48.6%), 11

29.7%), 7 (18.9%) and 1 (2.7%) patients carried 1, 2, 3 and 5 implants, respectively. In turn, 30

(81.1%), 6 (16.2%) and 1 (16.2%) patients respectively had 2, 4 and 6 teeth examined. A total of 196

implants sites and 360 tooth sites were recorded.

Overall, 8 (21.62%) out of the 37 patients presented with active periodontal disease (residual pockets

≥5mm with bleeding on probing), 16 (43.24%) were controlled individuals with history of chronic

periodontitis (no residual pockets ≥5mm) and 13 (35.14%) were not diagnosed with active or history

of periodontitis (no pockets ≥5mm). Regarding the level of radiographic attachment loss, 5.40% (2

patients) presented advanced loss of support in the dentition (>50%), 24.33% (9 patients) with

moderate loss (30%-50%) and 70.27% (26 patients) with mild attachment loss (<30%). The grade of

attachment loss was neither associated with the width of the KT and/nor the KM (p=0.22).

Overall, 45 edentulous gaps were analyzed of which, 26 were assessed in the posterior mandible,

followed by 17 in the posterior maxilla and a vast minority in the anterior regions (2). According to

the location, the posterior mandible was the most common area displaying <2mm of KM (77%), while

this was less frequently in the other locations. In this area, 53.8% accounted for <2mm of KM, while

in the posterior maxilla 17.6%. On the other side, 82.4% and 100% of the posterior and anterior

maxillary sites, respectively, and 46.2% and 0% in the posterior and anterior mandibular sites,

respectively, displayed ≥2mm of KM.

Significance of KM in relation to peri-implant condition

The vast majority of the implants examined presenting a band of ≥2mm of KM displayed mucosal

attachment (92%), while AM could not be found in implants with <2mm of KM (0%). When

comparing a KM band of < 2 mm versus ≥ 2 mm, with the exception of SUP, all the clinical and

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radiographic parameters were significantly increased when the band was < 2 mm (Table 1 and Figure

1). Moreover, KM was positively associated with VD. A lack of KM was significantly associated with

peri-implantitis (p<0.001).

The width of the KM band was significantly associated (p<0.001) with the health and peri-implantitis

rates, but not with peri-implant mucositis (Figure 2). Interestingly, under the presence of KM, on

comparing a band ranging from 0 to 1.99mm versus ≥ 2 mm, only mucositis was found to be

significantly greater (p<0.05) in the < 2 mm group. Neither peri-implantitis nor healthy implants

differed between these study groups.

Significance of KM in relation to comfort upon brushing

In the presence of a KM band of < 2 mm, the VAS score decreased significantly (p<0.001).

Interestingly, when the mean KM band was 2.5 mm, all the patients reported maximum comfort

(VAS=100).

Association between KM and KT of the adjacent dentition

The mean KM band width was 2.35±1.83 mm (range 0-6.33 mm), with a median of 2.2 mm. In 40%

of the edentulous implant-supported sites, the mean KM band was < 2 mm, while the remaining 60%

presented a KM band width of ≥ 2 mm. On the other hand, the KT band width was substantially

greater, with a mean value of 3.49±1.12 mm (range 1-6.50 mm) and a median of 3.50 mm.

The correlation between KM and KT of the adjacent teeth was statistically significant (p=0.002;

r=0.55). In other words, in scenarios characterized by a lack or narrow band of KM, the KT band of

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the adjacent teeth was significantly narrower. When analyzed according to the location, it was

exhibited that the correlation was strongly associated by the locations in the posterior maxilla (r=0.56;

p=0.018), while not in the posterior mandibular sites (r=0.07; p=0.71). Namely, in the posterior

mandible, the KM was significantly lower compared to adjacent KT sites, while in the posterior

maxilla, KM was significantly associated with the KT of the adjacent teeth (median KT: 4.00mm;

median KM: 3.67). However, in none of the cases was a lack of KM associated with a lack of KT of

any of the adjacent teeth. This underscore that the lack of KM constitutes a site-specific phenomenon.

Association of KM with implant site level

The KM was shown to be wider at the mesial (p=0.01) and distal line angles (p=0.01) of the implants,

and significantly narrower at the medial sites. Nevertheless, on considering the median values, KM

was equal at the three buccal sites, those measuring ≥ 2 mm ranging from 60.6% to 61.5%. Again,

significantly greater values were recorded for PPD, PI and MBL at sites measuring < 2 mm. In

relation to mBI, although a positive trend was observed, statistical significance was not reached

(p=0.05). The statistical relationship became stronger at DB (disto-buccal) sites for all the clinical and

radiographic parameters (p<0.001), except SUP (p=0.73).

Association between KM and periodontal condition

The periodontal condition was seen to be independent of KM band width. However, mBI increased

significantly in teeth adjacent to peri-implantitis implants (p=0.007).

Association between peri-implant and periodontal parameters

A positive correlation was found among PPD, mBI and PI in the assessed implants and adjacent teeth

(r=0.5) (Table 2 and Figure 3). Nevertheless, this fact was inconsistent with the presence (and width)

or absence of KM or KT.

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Discussion

Principal findings

There has been much debate on the potential impact of KM upon peri-implant conditions.

Based on previous clinical trials, its influence in relation to peri-implant bone loss is

equivocal.34-38 Nevertheless, it seems clear that scenarios characterized by a lack or

insufficient band of KM are more susceptible to increased signs of inflammation, including

erythema, bleeding on probing and tumefaction. The great disparity of the existing evidence

is referred to one predominant aspect. Data found in the literature suggests no association

between KM and peri-implant conditions in patients with adequate plaque control.39 Along

these lines, it is worth mentioning that implant/restorative surface topography might play a

role on biofilm development.40 Our own results partially concur with this, since in erratic

maintenance compliers, a KM band width of < 2 mm was significantly associated with more

unfavorable peri-implant conditions, discomfort while brushing, and a decrease in VD -

which in turn may decrease patient ability to correctly implement personalized oral hygiene

measures.

On the other hand, it has been shown that a lack of KM is a site-specific condition.

Nevertheless, it is remarkable that there is a positive correlation between KM and KT of the

adjacent teeth. In other words, when the KT band of the adjacent teeth is narrow, it increases

the probability of a narrow or inexistent KM on the buccal site of the implants. In any case, a

lack of KM always occurs in the presence of KT. Along these lines, it is important to note

that in scenarios characterized by a lack of KM, mBI was found to be greater at sites adjacent

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to those implants with peri-implantitis. Hence, it seems reasonable to suggest that a lack of

KM plays a limited role in relation to the adjacent periodontal condition.

Agreements and disagreements with previous studies

Our clinical findings support the view that KM around dental implants in erratic maintenance

compliers seems necessary for maintaining peri-implant health, and are consistent with

previously reported pre-clinical9, 41 and clinical observations34-38. Moreover, recent data have

evidenced the influence of the width of KM upon the peri-implant clinical parameters in

relation to the onset and resolution of experimental peri-mucositis in humans.42 The data are

not fully consistent throughout the literature, however.8, 10, 43, 44 It has been speculated that

these disagreements are partly due to the patient selection process involved. For instance, it

must be noted that the patients enrolled in the aforementioned studies followed adequate

professionally administered plaque control measures within university settings. In

comparison, our cohort of patients were treated and restored in private practice and were

erratic maintenance compliers. Hence, we partially concur with the findings indicating the

absence of a relationship between KM and peri-implant conditions, since under conditions of

adequate supportive peri-implant maintenance, the association might be negligible.

Likewise, there seems to be consensus on the brushing comfort conferred by ≥ 2 mm of

KM45. In the absence of KM, there is a mobile lining mucosa rich in elastic fibers and poor in

collagen.46 This agrees with the findings of a recent cross-sectional comparative study in

which implant sites with a KM band width of < 2 mm were found to be more prone to

brushing discomfort, plaque accumulation and peri-implant soft tissue inflammation.16 In

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contrast, two recent studies failed to support the association between the absence of KM and

discomfort during brushing.33, 47

This is certainly an area of controversy where the patient

pain threshold, brushing strength, mucosal thickness and other anatomy-related factors may

play important roles.

The positive association between KM and VD is of key importance, since it implies that a

shallow VD could interfere with proper oral hygiene techniques, thus leading to more plaque

accumulation. This finding is in agreement with a previous clinical study reporting the

association between VD and a lack of KM, and also increased bone loss and mucosal

recession around implants15 and natural dentition.48

Although a correlation was observed between KM and KT, a complete absence of KM was

not associated with a lack of KT - thus defining the former as a site-specific condition. This

critical finding suggests that there is a remodeling of soft tissues in the same way as there is a

remodeling of hard tissues after the extraction of a tooth.49

Limitations and recommendations for future research

Our study has a number of limitations. Firstly, a number of variables were not accounted for, such as

the width of KM/KT on the lingual aspect, keratinized tissue thickness or mucosal/gingival recession.

However, it must be mentioned that for the diagnosis of peri-implant conditions, the lingual sites

considered had to be bordered by sufficient KM. Because of the study design involved, a cause-effect

relationship cannot be claimed between peri-implant clinical parameters and KM. In this sense, it

should be highlighted that future studies should monitor the peri-implant clinical and radiographic

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parameters in a longitudinal basis to assess the changes over time in the presence/lack of KM.

Furthermore, it would be of particular interest to evaluate the dynamics of the band of KM according

to the peri-implant condition. Moreover, it must be noted that these findings are not applicable to

good maintenance compliers, where conflicting results have been reported regarding the significance

of KM.

Conclusion

The presence of < 2 mm of KM around dental implants in erratic maintenance compliers seems to be

associated with peri-implant diseases. The lack of KM constitutes a site-specific phenomenon

independent of the keratinized tissue present in the adjacent dentition.

Acknowledgments

The authors wish to acknowledge the FEDICOM Foundation (Badajoz, Spain) for financial support of

the statistical analysis.

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Figure Legend

Figure 1. Clinical and radiographic parameters according to the width of the band of keratinized

mucosa (<2mm)/≥2mm)

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Figure 2. Implant diagnosis according to the width of keratinized mucosa.

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Figure 3. Plots showing the associations corresponding to periodontal and peri-implant parameters.

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 Figure 4. Case showing the clinical poor oral hygiene (A) in an erratic maintenance complier, where
in the presence of a wide band of keratinized mucosa, marginal bone loss has not progressed to a
pathological condition (B).

Tables

Table 1. Descriptive analysis of the clinical and radiographic parameters according to the width of

keratinized mucosa.

Keratinized mucosa

Keratinized mucosa

Differential r (p-value)
<2 mm ≥2 mm p-value
coefficient

n 26 40

PPD (mm) 4.86 ± 1.06 (5.00) 3.65 ± 1.06 (3.33) -1.21 ± 0.28 <0.001*** -0.57

(p<0.001***)

mBI 1.15 ± 0.69 (1.17) 0.46 ± 0.57 (0.17) -0.69 ± 0.17 <0.001*** -0.54

(p<0.001***)

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SUP 0.08 ± 0.20 (0.00) 0.06 ± 0.18 (0.00) -0.02 ± 0.04 0.666 -0.11

(p=0.463)

PI 1.08 ± 0.86 (1.00) 0.28 ± 0.41 (0.00) -0.79 ± 0.21 <0.001*** -0.60

(p<0.001***)

MBL (mm) 2.03 ± 1.65 (2.10) 0.64 ± 0.93 (0.20) -1.39 ± 0.41 0.001** -0.55

(p<0.001***)

VAS (%) 53.8 ± 30.7 (60.0) 97.0 ± 8.5 (100.0) 43.2 ± 6.49 <0.001*** 0.703

(p<0.001***)

VD <4mm 22 (95.7%) 7 (18.9%)

<0.001***
≥4mm 1 (4.3%) 30 (81.1%)

Implant diagnosis

Healthy 4 (16.0%) 21 (53.8%)

Mucositis 10 (40.0%) 16 (41.0%) <0.001***

Peri-implantitis 11 (44.0%) 2 (5.1%)

*p<0.05; **p<0.01; ***p<0.001, in brackets: median value

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Table 2. Correlations between the clinical and radiographic parameters between implants and their

adjacent dentition.

Implants

PPD mBI SUP PI MBL KM VAS

Dentition PPD 0.32 0.10 -0.10 0.21 0.19 -0.23 -0.26

(0.034*) (0.504) (0.532) (0.176) (0.216) (0.137) (0.09)

mBI 0.47 0.42 0.11 0.38 0.25 -0.25 -0.16

(0.001**) (0.005**) (0.454) (0.011*) (0.103) (0.10) (0.307)

SUP --- --- --- --- --- --- ---

PI 0.39 0.37 0.16 0.43 0.20 -0.10 0.09

(0.009**) (0.013*) (0.293) (0.001**) (0.188) (0.519) (0.541)

KT -0.14 0.01 -0.14 0.18 -0.10 0.45 0.16

(0.367) (0.927) (0.358) (0.242) (0.520) (0.002**) (0.283)

VAS (%) -0.03 0.15 0.02 0.05 0.13 0.20 0.40

(0.871) (0.321) (0.902) (0.770) (0.380) (0.179) (0.007**)

*p<0.05; **p<0.01; ***p<0.001

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